INFORMED PATIENT CONSENT FOR SURGICAL OPERATION,
MEDICAL PROCEDURES AND/ OR TREATMENT
ACKNOWLEDGEMENT OF RECEIPT OF MEDICAL INFORMATION
Material Risks Identified by Physician – Daniel R. Yanicko, Jr., M.D.
INFORMATION ABOUT THIS DOCUMENT – READ CAREFULLY BEFORE SIGNING
TO THE PATIENT: You have been told that you should consider medical treatment/surgery.
This document will outline for you (1) the nature of your condition, (2) the general nature of the
medical treatment/surgery, (3) the most common risks of the proposed treatment/surgery, as
determined by your doctor, (4) reasonable therapeutic alternatives and material risks associated
with such alternatives, and (5) risks of no treatment.
You have the right, as a patient, to be informed of your condition and the recommended surgical,
medical, or diagnostic procedure to be used so that you make the decision whether or not to
undergo the procedure after knowing the risks and hazards involved. In keeping with the Informed
Consent recommendations, you are being asked to sign a confirmation that we have discussed all
these matters. Please read the form completely. As we have already discussed the common
problems and risks with you, we wish to inform you as completely as possible about your medical
treatment/surgery. Ask questions about anything you do not understand about, and we will be
pleased to explain further.
PATIENT NAME: _________________________________
DIAGNOSIS/IMPRESSION: ________________________________________________
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SURGICAL PROCEDURE (S): ______________________________________________
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REASONABLE THERAPUETIC ALTERNATIVES TO SURGERY: Surgical and nonsurgical options have been discussed with the patient, and questions were answered for the relative
advantages and disadvantages of the recommended operation/medical treatment, including risks of
no treatment or surgery for this condition.
FURTHERMORE, I understand there are risks in this Operation/Treatment/Special Procedure,
but I DO NOT wish to know all the details and trust the Doctor’s professional ability to carry out
the PROPOSED SURGICAL TREATMENT PLAN and/or medical treatment care as deemed
appropriate and necessary for my ultimate benefit.
INFORMED CONSENT – Daniel R. Yanicko, Jr., M.D.
Page 2
Material Risks:
All medical or surgical treatment involves risks. Listed on the next few pages are those risks
associated with this procedure that we believe a reasonable person in your (the patient’s) position
would likely consider significant when deciding whether to have or forego the proposed treatment.
Please ask your physician if you would like additional information regarding the nature or
consequences, the likelihood of occurrence, or other associated risks that you might consider
significant but may not be listed in this document.
MUSCULOSKELETAL TREATMENTS AND PROCEDURES
A surgical procedure upon, or even a closed manipulation of an extremity, entails risk to a greater
or lesser degree, to all major systems of that limb, and can result in varying degrees of weakness,
deformity, bleeding, infection, disfiguring scars, paralysis (loss of function), pain, numbness,
amputation, and/or limitation of joint range of motion.
Anesthesia complications can include heart attack, stroke, brain damage, pneumonia, and death.
Furthermore, the goals/expected outcome of the procedure may not be obtained and other medical
therapy/surgical treatments may become necessary to achieve the goals of the original operation.
COMPLICATION LIST FOR ALL ORTHOPEDIC SURGICAL PROCEDURES:
Uncommon Risks --severe bleeding that requires blood transfusion; scars-sometimes overly
thickened to keloid formation; infection; continued or worsened pain/stiffness or deformity;
failure of tissue/bone healing; hardware/prosthesis implant failure and need for early
removal or revision; blood clots to legs (phlebitis) deep vein thrombosis and /or blood clots
to lungs (pulmonary embolus).
Very Uncommon Risks --artery, vein, nerve, or tendon damage; amputation; paralysis or loss of
limb/ joint function; need for later implant removal, with or without revision.
ADDITIONAL SPECIFIC RISKS FOR VARIOUS ORTHOPEDIC PROCEDURES:
o FRACTURE REPAIR: OPEN REDUCTION and INTERNAL FIXATION by METAL
PLATES, SCREWS, WIRE CABLES, PINS and/ or IM RODS – Uncommon Risks -Metal fatigue/breakage with the need for later removal; Failure of bone healing (nonunion)
or delayed union; Improper bone healing with shortening or angular deformity (malunion);
Loss of motion, joint stiffness, growth plate malfunction or joint arthritis; and Pain due to
extra bone, cartilage damage, and/or scar formation.
o OPERATIVE ARTHROSCOPY OF JOINTS / ANTERIOR CRUCIATE
LIGAMENT RECONSTRUCTION -- KNEE – Common Risks -- Postoperative
swelling / bleeding. Uncommon Risks -- Scar formation with loss of motion; Cartilage
damage and/or progression of arthritis; Graft failure or rejection.
o TOTAL KNEE REPLACEMENT – Common Risks -- Permanent lateral knee skin
sensory loss – lateral branch of the saphenous nerve. Uncommon Risks -- Limitation of
motion and pain due to extra bone formation/ scar. Very Uncommon Risks -- Bone
fracture-femur, tibia, or patella (kneecap); Ligament damage; Loosening or dislocation of
knee/prosthetic parts; Rupture/ tear of patellar/quadriceps tendon(s) or collateral ligaments.
INFORMED CONSENT – Daniel R. Yanicko, Jr., M.D.
Page 3
o TOTAL HIP REPLACEMENT/BIPOLAR HEMIARTHROPLASTY – Uncommon
Risks -- Limitation of motion due to extra bone formation or scar; Leg length inequality or
change; Groin and/or thigh pain; Bone fracture – femur or pelvis; Loosening and/ or
dislocation of hip/ prosthetic parts; Nerve and/or artery injuries that impair function.
o JOINT FUSION -- An operation to remove the damaged arthritic and/or infected joint by
healing the bones involved together to produce permanent loss of joint motion.
Uncommon Risks -- Deformity; Failure to heal properly-malunion or nonunion;
Need for later hardware removal; Residual pain at the fusion site or other nearby joints.
o SHOULDER SURGERY: ACROMIOPLASTY, BICEPS TENDON and LABRAL /
CAPSULE / ROTATOR CUFF REPAIR, and TOTAL / REVERSE / PARTIAL
SHOULDER REPLACEMENT – Uncommon Risks -- Recurrent tear of the repaired
tendon and/or instability or joint dislocation; Arthritis; Loss of motion due to scarring;
Loosening, malposition and/or dislocation of prosthetic parts.
o HAND SURGERY: CARPAL TUNNEL RELEASE; ULNAR NERVE
TRANSPOSITION; THUMB 1st CARPOMETACARPAL JOINT TENDON
INTERPOSITION ARTHROPLASTY; TENDON/ NERVE/MUSCLE REPAIR;
SYNOVECTOMY or TENDON SHEATH RELEASE, TENDON TRANSFER (S),
TUMOR REMOVAL; JOINT RECONSTRUCTION or FUSION – Uncommon Risks -Incomplete return of hand function, sensation, and/or grip strength; Arthritis; Failure to
relieve numbness/pain; Scarring of tendon or nerve that prevents normal motion and
function; Recurrent rupture of tendon/muscle; Swelling/pain at incision site and entire
hand/finger; Loosening of joint or malposition, deformity, or loss of motion.
o ANKLE/ FOOT SURGERY: TENDON TRANSFER, OSTEOTOMY and/or JOINT
FUSION; ANKLE LIGAMENT RECONSTRUCTION; ANKLE/SUBTALAR JOINT
FUSION or TRIPLE ARTHRODESIS; BUNIONECTOMY; HAMMER/CLAW/MALLET
TOE REPAIRS; CYST/TUMOR REMOVAL; PLANTAR FASCIA RELEASE –
Uncommon Risks -- Loss of motion; return of cyst/tumor; incomplete fusion or loosening
of joint parts; need for later implant or metal removal.
ACKNOWLEDGEMENT – AUTHORIZATION AND CONSENT
Dr. Yanicko has discussed this material with me. All information given me, and, in particular,
all estimates made as to the prospects of success or the likelihood of occurrence of risks of this
medical treatment, surgery, or alternative procedure, are made in the best professional judgment of
my physician. Further, I understand that no guarantees about any surgery and/or medical treatment
outcome can be given to me. As such, I impose no specific limitation(s) to my care by the
Doctor unless written here________________________________________________________
_______________________________________________________________________________
The nature and possibility of complications cannot always be accurately anticipated. Therefore,
there is and can be no guarantee (either expressed or implied) as to the ultimate success and results of
the medical treatment or surgical procedure(s). Nothing further has been said to me; no other
informational materials have been given to me; and I have not relied upon any other information
that is inconsistent with or contrary to the written explanations set forth in this document.
INFORMED CONSENT – Daniel R. Yanicko, Jr., M.D.
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Consent: I hereby authorize, consent thereto and direct Daniel R. Yanicko, Jr., M.D., together
with associates and/or assistants of his choice, to administer or perform the above-listed medical
treatment/surgical procedure described in this Consent form; including any additional procedures
or services as they may deem necessary or reasonable. This includes: if needed, administration of
general or regional anesthesia by or under the direction and supervision of a member of the
Department of Anesthesia; the administration of local anesthesia or conscious sedation by the
Doctor performing my procedure; administration of x-rays or other radiologic services; laboratory
services; insertion of bone graft substitutes or calcium bone void fillers; and the disposal,
examination, or preservation for study of any tissue removed during the surgical procedure(s).
___ Blood transfusion is not generally needed with this procedure.
___ If needed, I consent to the use of blood and /or blood products, as deemed necessary.
Specific risks associated with transfusion include: fever, rash, heart failure, acute/chronic liver
inflammation/viral infection called Hepatitis B/C that can lead to scarring and/or cirrhosis, other
blood infections, AIDS (acquired immune deficiency syndrome), and/or transfusion reactions that
may cause kidney failure, anaphylactic shock, anemia or death.
Furthermore, I understand the material as presented above, and I have reviewed all information
presented in this document and hereby acknowledge that I have had the opportunity to ask any
questions about the contemplated medical treatment/surgical procedure (including risks, benefits,
complications, and alternatives), and state that any and all of my questions have been answered to
my complete satisfaction. I have read and understand all information set forth in this document,
and all blanks were filled in prior to my signature.
Signature of Patient or Authorized Person: ________________________________________
Printed Name: ___________________________________ Date/Time: ____________________
____If patient is a minor or unable to consent -- list age and/or reasons and list relationship.
Witness Certification: The patient was informed and appears to understand all material covered in
this Informed Consent document, and signed this form on the indicated date and time noted.
Signature of Witness: _____________________________ Date/Time: _____________________
Printed Name: _______________________________
Physician Certification: I hereby certify that I have provided and explained the information set
forth, herein, and answered all questions of the patient, family members and / or the patient’s
authorized person, concerning the medical treatment or surgical procedure(s), to the best of my
knowledge and ability as a Board-certified Orthopaedic Surgeon.
Signature of Physician: ________________________________Date/Time: _________________
Daniel R. Yanicko, Jr., M.D.
____ To help me understand and consent for my operation, medical treatment, and/or procedure -this form has been translated into _______________ by __________________________